New Zealand Guidelines For ADHD

Guidelines for the assessment and treatment
of Attention-Deficit/Hyperactivity Disorder will help
health professionals make good decisions when helping
children with this condition.

The New Zealand Guidelines
for the Assessment and Treatment of
Attention-Deficit/Hyperactivity Disorder were released by
the Ministry of Health today and are primarily aimed at
paediatricians, general practitioners, and child and
adolescent psychiatrists. They will also be of considerable
value to all other health professionals who work with
children and to parents who want accurate
information.

Child and Youth Health Chief Advisor Dr
Pat Tuohy said he hoped the guidelines would lead to early
recognition of ADHD and ensure all children and young people
with ADHD receive appropriate treatment.

"When assessing
and treating children with ADHD New Zealand's health
professionals will now be able to refer to a consistent set
of guidelines based on international evidence.

"Early
recognition and good management of ADHD will enable
children with ADHD to better participate in education,
recreation and family life. The Guidelines are also expected
to reduce the stigma associated with ADHD and its medical
treatment."

Attention-Deficit/Hyperactivity Disorder is
a biological disorder and may affect three to five out of
every 100 school children between six and 14 years old. It
is characterised by persistent overactivity,
impulsiveness and inattention which significantly impacts on
a child's life. If left untreated it can cause considerable
stress for children, families and schools.

The guidelines
cover clinical assessment, diagnostic criteria, ADHD
questionnaires, methods of evaluation, treatment and
information on support services. They are based on similar
guidelines used in Australia and the United States and were
developed by a multi disciplinary group using the best
international studies and evidence available.

Dr Tuohy
said the guidelines will assist health professionals with
the assessment of children who present with any disruptive
behaviour problems.

"Wherever possible health
professionals should get information from the child,
parents, caregivers and school personnel and use appropriate
and specific questionnaires for ADHD. There should be
observations of the child in more than one environment by
various people before a diagnosis is made.

"The holistic
and cultural needs of the child and family should also be
taken into account. The assessment and treatment of any
other disorders or common problems such as emotional and
behavioural disorders and learning problems is also very
important." The guidelines will also assist with decisions
on the best treatment for children with ADHD.

"Studies
show that a carefully executed regimen of medication
is more effective than behavioural treatment alone. Whether
combined treatment - medication and behavioural treatment -
is more effective than medication alone is less clear," Dr
Tuohy said.

"We accept there are widely differing
opinions and approaches to the treatment of ADHD. These
guidelines are based on the premise that health
professionals have a responsibility to ensure children
get the most effective treatment that can be offered for
their condition. This has been determined by careful
evaluation of the evidence from the studies
available."

The 63-page book of guidelines has been sent
to health professionals and is also available on the
Ministry of Health website www.moh.govt.nz.

What is
ADHD? Attention-Deficit/Hyperactivity Disorder is a
biological disorder and may affect three to five out of
every 100 school children between six and 14 years old. It
is characterised by persistent overactivity, impulsiveness
and inattention which significantly impacts on a child's
life. This can lead to significant impairment across a range
of settings.

What causes ADHD? Genetic causes are the
most common. The impairment in ADHD is likely to be caused
by a variety of neurological factors involving the activity
in the frontal lobe of the brain where executive decisions
are made.

Why do health professionals need guidelines for
the treatment and assessment of ADHD? In 1998 and 1999
there was growing public interest and awareness of ADHD as a
condition and stimulant medication as a treatment. The
individual and societal costs of ADHD and the
increasing prescription rate of Ritalin and other stimulant
drugs was being questioned. The Ministry took heed of public
demands for increased recognition and management of the
condition and started the process which would lead to
development of the guidelines.

Who was in the group that
developed the New Zealand Guidelines? The group included
child and adolescent psychiatrists, paediatricians,
general practitioners, the Ministry of Education, and ADHD
group support representatives. For a detailed list see the
Guidelines.

What studies were consulted by the group
putting the Guidelines together? ADHD is one of the most
widely and well-researched conditions in childhood. The
process for developing the Guidelines involved an analysis
of recent evidence-based systematic reviews and consensus
conferences from the United States of America and Australia.
Previous work by Professor John Werry was also
included.

Why did the guidelines take two years to
develop? The guideline development process began with
Medsafe but the need for broader expert involvement led to
the project being transferred to the Ministry of Health's
Personal Health Directorate. The first meeting of the multi
disciplinary group charged with developing the guidelines
was on June 18 1999 and at that stage it was unclear how
long it would take. Developing guidelines is a complex
process which usually takes one to two years. The process
involved a number of drafts and extensive discussion by the
reference group that developed the Guidelines.

What
guidelines existed for health professionals before now? New
Zealand health professionals have been able to consult a
number of authoritative texts including Professor R A
Barclay's book "Attention Deficit Disorder Handbook: A
Handbook for Diagnosis and Treatment, and Professor Werry's
book "A Practitioners Guide to Psychoactive Drugs for
Children and Adolescents". Position statements from the
American Academy of Paediatrics and Practice Parameters of
the American Academy of Child and Adolescent Psychiatry were
also consulted by health professionals.

What do the
guidelines say about the prescription of Methylphenidate
(Ritalin) and other stimulants? The guidelines say that
as a general rule after a comprehensive mental health
assessment and after the health professional has carried out
all the principles described in the Guidelines,
medication should be considered if appropriate.
Methylphenidate and dexamphetamine are regarded as a first
choice pharmacological agents in the treatment of ADHD.
After the medication has been well stabilised there should
be regular reviews of its continued and long-term
use.

What do the guidelines say about other treatments
like diet treatment? Dietary treatment is popular among
many parents and some clinicians but clinical trials have
not produced sufficient evidence to recommend its use. Where
parents initiate this treatment themselves, the
practitioner should ensure that it is undertaken as safely
as possible and should refer the family to a dietician.

Are there side effects for the child where medication is
prescribed? Studies evaluating adverse effects of
medication suggest most side effects of methylphenidate
and dexamphetamine are relatively mild, of short duration
and respond to dosing or timing adjustments. There appear to
be no long term serious effects.

What other elements of
treatment would a child with ADHD benefit from? Careful and
regular monitoring of treatment effects including side
effects, annual specialist reviews, treatment of any
coexisting problems, comprehensive care for families that
caters to their particular needs, that is holistic and
culturally appropriate, linking parents with local support
groups and effective management in the education setting.

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